Update Newsletter
December 2007
Get Ready for HEDIS 2008 2
Health Safety Net Replaces Uncompensated
Care Pool 2
Differentiating Commonwealth Care Alliance 2
Standardized Behavioral-Health Screens for
MassHealth Members Under Age 21 2
MassHealth Reminders 4
Going Electronic: A Provider’s Success Story
After making the transition to electronic claims submission, a MassHealth provider shares her experience on how going electronic has greatly improved business procedures.
Sue (not her real name) works in a small, independent practice. Before October 2007, all the practice’s MassHealth billing was done using the paper-submission process.
In October 2007, Sue decided to try electronic claims submission using MassHealth’s Provider Claims Submission Software (PCSS). The result was a success. In fact, claims are now processing faster than in the past, and the denial rate has been reduced.
While Sue admitted the testing process did involve a bit of trial and error before she became familiar with the protocols, she felt it was easy to understand, and the benefits received from electronic billing made the transition worthwhile.
She was quick to mention how the responsiveness and knowledge of the MassHealth Health Insurance Portability and Accountability Act (HIPAA) Support representatives were a big help in ensuring a seamless and stress-free billing transition.
The best thing about claims submission? Sue says without a doubt is its easy accessibility. Other providers have shared this sentiment, mentioning that with a laptop, claims can be submitted from any location, at any time, as long as they have a connection to the Internet. This ease and portability translates into high time-savings, and fits into busy and hectic work schedules.
Sue and her office were so impressed by the benefits of moving to electronic claims submission that they began to use some of MassHealth’s other automated solutions. For example, Sue’s office now uses MassHealth’s Web-based Recipient Eligibility Verification System (WebREVS) to verify member eligibility and check claims status. Previously, they had relied upon the Automated Voice Response (AVR) system, but since transitioning to WebREVS, they have been impressed with its ease of use and efficiency over AVR.
So would Sue recommend electronic claims submission and MassHealth’s other self-service options to providers? An enthusiastic “absolutely.” She now spends significantly less time processing claims, has dramatically cut down on paper accumulation, and receives fewer denied claims. After making the change, she has no regrets and admits she would never go back to the antiquated paper- claim processes.
Be the Next Success Story
Don’t miss out—you could experience all the benefits Sue’s office now shares. If you are not currently submitting your claims electronically, contact MassHealth HIPAA Support at 1-800-841-2900 or e-mail hipaasupport@mahealth.net.
Payment Error Rate Measurement Project
Massachusetts Medicaid is one of 17 states participating in the 2007 Centers for Medicare & Medicaid Services (CMS) Payment Error Rate Measurement (PERM) project, an intiative designed to estimate a national and state Medicaid payment error rate and identify opportunities for improvement.
In participation with this program, roughly 2,000 paid or denied claims received by MassHealth for the CMS fiscal year ending September 30, 2007, will be randomly selected by CMS and their partners. Sampling will be taken from four quarterly claim-file extracts throughout the 2007 fiscal year, and tested by CMS for accuracy and medical necessity.
Providers randomly selected for participation will be contacted directly by the CMS contract, Livanta LLC. Providers will be asked to verify name and address information, determine how they want to receive the request for information (RFI) for medical records (fax or U.S. mail), and provide medical records and supporting documentation for the sampled claim(s).
Selected participants are required to respond to the RFI within 90 days of receipt. Livanta LLC will follow up to ensure that selected parties have adequate time to submit the documentation before the 90-day time frame expires. If there are any discrepancies or errors after the records have been received and processed, providers will be notified and given the opportunity to respond.
Participation for selected providers is essential, as failure to respond to the RFI in the specified time frame will result in a claim-processing error and subsequent adjustment against the claim. Additionally, the provider may be subject to an on-site review.
Visit CMS’s PERM Web site at
http://www.cms.hhs.gov/perm for complete information about the CMS PERM Project.
For questions about a medical-record request, call Livanta’s customer service representatives at 1-301-957-2360.
Additional information is also available from MassHealth in All Provider Bulletin 166 (June 2007), accessible from the Provider Library at the MassHealth Web site, and from the December 2007 Feature of the Month, accessible from the Information for MassHealth Providers link on www.mass.gov/masshealth.
Get Ready for HEDIS 2008
The Healthcare Effectiveness Data and Information Set (HEDIS), previously known as the Health Plan Employer Data and Information Set, is a set of standardized performance measures designed to ensure that purchasers and consumers have the information they need to reliably compare the performance of managed- health-care organizations.
The Primary Care Clinician (PCC) Plan is gearing up for HEDIS 2008 and needs your assistance. The PCC Plan expects to contract with MedAssurant to perform the medical-record-review
component. The HEDIS 2008 measures
that will require chart reviews include:
childhood immunization status; and
well-child visits in the first 15 months.
The medical record reviews will begin in March 2008. The reviews may be conducted at your office or you may be requested to mail or fax copies of randomly selected PCC Plan members’ records directly to MedAssurant. It is imperative to the success of the project that all medical records be retrieved. Every record counts, so please respond to all requests from MedAssurant in a timely manner.
Your participation and cooperation throughout this endeavor is greatly
appreciated.
MassHealth thanks you in advance for your assistance.
Note: HEDIS is a registered trademark of the National Committee for Quality
Assurance.
Health Safety Net Replaces the Uncompensated Care Pool
Effective October 1, 2007, the Health Safety Net (HSN) succeeded the Uncompensated Care Pool (UCP). The links listed below give more information related to the transition, including new patient and provider frequently asked questions.
To access regulations for the HSN and frequently asked questions, go to
www.mass.gov/healthsafetynet.
You can also review Transmittal Letter (TL) ALL-153 (October 2007) for a listing of all the Recipient Eligibility Verification System (REVS) message changes. TL ALL-153 is available from the Transmittal Letters section of the Provider Library, accessible from www.mass.gov/masshealthpubs.
Standardized Behavioral-Health Screens for MassHealth Members Under Age 21
Behavioral-health screenings are a critical component of preventive, primary-care visits for children. MassHealth is implementing new requirements for behavioral-health screenings for children under the age of 21.
Using Standardized Tools to Screen for
Behavioral-Health Concerns
Effective December 31, 2007, all primary-care providers (including providers enrolled in the Primary Care Clinician (PCC) Plan) who serve MassHealth-enrolled children and young adults under the age of 21 (except MassHealth Limited) must offer to conduct a behavioral-health screen at each Early and Periodic Screening, Diagnosis and Treatment (EPSDT) and Pediatric Preventive Healthcare Screening and Diagnosis (PPHSD) visit, as described by Appendix W of your MassHealth provider manual. Appendix W contains a menu of approved screening tools from which to choose.
Menu of Standardized Behavioral-Health
Screening Tools
The menu of behavioral-health screening tools in Appendix W accommodates a range of ages while permitting some flexibility for provider preference and clinical judgment. The menu of behavioral-health screening tools is displayed below. Please note that this table is for your information only. Appendix W is the controlling reference for the approved behavioral-health screening tools.
Billing for Standardized Tools
MassHealth will pay for the administration and scoring of a standardized behavioral-health screening tool in addition to, and separately from, the office visit.
Effective December 31, 2007, providers must submit claims using Healthcare Common Procedure Coding System (HCPCS) Service Code 96110. Starting July 1, 2008, MassHealth will deny any claim for Service Code 96110 that is submitted without a modifier. The modifiers are provider type-specific and indicate whether the screen identified a behavioral health need or not. Identification of a behavioral-health need includes needs identified in the areas of social-emotional well-being and mental health. Consult the billing guidelines in your provider manual for more information the modifiers and about how to bill the behavioral- health screen.
To review any of the information outlined in the MassHealth Provider Manuals, go to the Provider Library link at
www.mass.gov/masshealth and select MassHealth Provider Manuals.
Training Opportunities
MassHealth will be offering online training opportunities in the future for you to learn more about how to administer and score the standardized behavioral-health screening tools (including tips for implementing the tools in your practice) and how to bill for the tools. The training on administering and scoring the tools will be available in December 2007. The training on billing the tools will be available in
January 2008.
Stay tuned to the MassHealth Children’s Behavioral Health Initiative Web site for links to the training, information about when training becomes available, and other updates about children’s behavioral health issues.
Make sure you keep checking in at www.mass.gov/masshealth/childbehavioralhealth to get the latest updates . The site will be active starting December 31, 2007.
MassHealth Reminders
Make Sure We Have Your Information
Ensure that MassHealth has your accurate provider-file information. Any time your business address, mailing address, or phone number changes, we need to know. Updating your information is as simple as completing the Provider Change of Address form, accessible from the Provider Forms link on
www.mass.gov/masshealth.
Not updating your correct doing-business-as (DBA) information will impact processing of your MassHealth claims information. Therefore, it is essential that you report your correct information to MassHealth any time your contact information changes.
Service Code 90715 and 90716
When submitting a claim to MassHealth for dispensing the tetanus, diphtheria toxoids and acelullar pertussis vaccine (Service Code 90715), or varicella vaccine (Service Code 90716) to an eligible MassHealth member, MassHealth will cover the vaccines only when administered to eligible members 19 years of age or older. For members 18 years of age and under, the state-supplied vaccine is provided free of charge and should be ordered from the Massachusetts Department of Public Health (DPH). Providers are advised to check the Recipient Eligibility Verification System (REVS) to verify member eligibility before administering vaccines.
Healthcare Common Procedure Coding System (HCPCS) Code 90732
Effective for dates of service on or after September 1, 2007, the pneumococcal polysaccharide vaccine (HCPCS code 90732) is no longer covered by MassHealth. For MassHealth-eligible members, the state-supplied vaccine should be ordered from the Massachusetts Department of Public Health (DPH). Providers are advised to check the Recipient Eligibility Verification System (REVS) to verify eligibility before administering the vaccine.
Updated Rates for Hospice Providers
Please be advised that the Division of Health Care Finance and Policy (DHCFP) has updated the hospice rates for MassHealth hospice providers, pursuant to regulation 114.3 CMR 43.04. This is effective for dates of service on or after
October 1, 2007.
To obtain the revised hospice rates by county, refer to DHCFP-issued Informational Bulletin 07-12, which is available at www.mass.gov/dhcfp by clicking on DHCFP Regulations, then Hospice Services, and Bulletin: Rate Update (under regulations at 114.3 CMR 43).
Using Only CMS-1500 for Claims Submitted
on or after September 1, 2007
Effective September 1, 2007, MassHealth will accept only the new CMS-1500 (Rev. 08/05) for all Medicare Part B crossover claims submitted on paper. Any claims received after this date submitted on the previous version of the HCFA-1500 have been, and will continue to be, returned to the provider unprocessed.
Updated Durable Medical Equipment (DME) and Oxygen Tool
The MassHealth DME and Oxygen Payment and Coverage Guideline Tools have been updated and posted to the MassHealth Web site. To ensure that you are using the most recent version of the tools, the date in the upper left of the header should be 11/05/07.
To access the updated tools, go to the MassHeallth Provider Library at
www.mass.gov/masshealthpubs. Click on Provider Library, then MassHealth Payment and Coverage Guideline Tools.
Claim Denials for Certain Service Codes
Certain claims submitted after June 01, 2007, with service codes L4205, L4210, L7510, and L7520 have denied for error 255 (“The procedure code entered on the claim requires prior authorization”).
Also, certain claims billed with Service Code L2275 denied for error 591 (“The procedure code entered on the claim exceeds the amount allowed.”)
MassHealth has corrected the issue and providers can now resubmit these claims for payment.
Please Note: The orthotics and prosthetics payment tool will be updated to reflect changes in prior-authorization requirements in the near future.